Narrowing Down the Symptomatology of Isolated Vascular Rings in Children.

Vascular rings may cause respiratory or gastrointestinal symptoms due to compression of the trachea and/or esophagus. Advances in imaging have enabled early detection in asymptomatic patients posing new management dilemmas. Surgery is expected to relieve symptoms, although this has not been well studied. We sought to evaluate the presence and pattern of symptoms associated with vascular rings before surgical intervention and to detail symptom resolution after surgery. A 10-year retrospective review of patients diagnosed with an isolated vascular ring was performed between January 2010 and December 2019. 100 patients were identified; 35 double aortic arch (DAA) and 65 right aortic arch and left ligamentum arteriosum (RALL). 73 patients were symptomatic on presentation; 47 had respiratory, 5 had gastrointestinal, and 21 had both types of symptoms. Surgical repair was performed in 75 patients; 74 were symptomatic. Respiratory symptoms were more likely in patients with preoperative tracheal narrowing (p < 0.001). Moderate-severe respiratory symptoms led to surgery in RALL patients (OR 10.6, p = 0.0001). DAA patients were more likely to undergo surgery (p < 0.001) irrespective of symptom severity. At a median post-surgical follow-up of 4 months, there was a significant reduction in symptom burden (p < 0.001), except for asthma symptoms (p = 0.131). Symptom resolution was not dependent on the vascular ring anatomy (p = 0.331) or the age at operation (p = 0.158). Vascular rings are typically accompanied by respiratory symptoms and less commonly GI symptoms, both of which resolve in most patients after surgery. Those who present predominantly with asthma-like symptoms may not achieve resolution after surgery.

Virtual Residency Interviews during the COVID-19 Pandemic: The Applicant's Perspective.

OBJECTIVES: The coronavirus disease 2019 (COVID-19) pandemic has had a profound impact on medical education at all levels, particularly on applicants applying to residency programs. The objective of the study was to gain a comprehensive understanding of applicants' perspectives on virtual interviews in the setting of the COVID-19 pandemic. METHODS: We conducted a quantitative survey and a qualitative study between March and April 2021. The link to an anonymous online survey was emailed to fourth-year medical students from one allopathic medical school. The survey link also was posted on the social media page of one allopathic medical school and one osteopathic medical school. Participants were then invited to participate in a follow-up 15- to 45-minute qualitative virtual interview. RESULTS: A total of 46 participants completed the survey, with a response rate of approximately 29.1%. The most beneficial aspect of the virtual interview was saving money on travel (31, 78.39%). In contrast, the least beneficial aspect of the virtual interview was the inability to personally explore the culture of the program (16, 34.78%), followed by the inability to explore the city and surrounding area (11, 23.91%). Thematic saturation was reached after interviewing 14 participants over Zoom. Four major themes of the virtual residency interview experience were discussed: virtual interviews offered many advantages, virtual interviews posed unique challenges, residency programs need more organizational improvements, and virtual specific preparations are needed. CONCLUSIONS: Despite the challenges associated with the virtual interview process, applicants rated the overall virtual interview experience positively. Given the continued impact of COVID-19 on medical education, the majority of residency programs will elect to continue virtual interviews for the 2022 Electronic Residency Application Services cycle. We hope that our findings may provide insight into the applicant's perspective on the virtual interview experience and help optimize virtual interviews for future cycles.

Diagnostic performance of the second-generation molecular tests in the assessment of indeterminate thyroid nodules: A systematic review and meta-analysis.

OBJECTIVE: The objective of this systematic review and meta-analysis was to evaluate the diagnostic performance of the second-generation molecular tests in the diagnosis of thyroid nodules with indeterminate fine-needle aspiration biopsy results. METHODS: We searched PubMed, Google Scholar, Scopus, and Cochrane Library for studies published between January 2017 and March 2021. Inclusion criteria were indeterminate thyroid results from fine-needle aspiration (FNA) that included Bethesda categories III and IV, use of Afirma GSC, Thyroseq v3, and ThyGeNext as an index test, and conclusive histopathological results. Studies with no post-surgical diagnoses were excluded. For each included study, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were obtained. Sensitivity and specificity were pooled jointly using a bivariate binomial random-effects model. Statistical significance was indicated at p-value less than 0.05. RESULTS: Our search yielded 431 non-duplicate articles, of which 15 were included in the study (7 GSC, 6 Thyroseq v3, and 2 ThyGeNext). ThyGeNext studies were excluded from the meta-analysis due to the small sample size. Pooled data for GSC studies on 472 thyroid nodules showed a sensitivity of 96.6 (95% confidence interval: 89.7-98.9%), specificity of 52.9% (23.4-80.5%), PPV of 63% (51-74%), and NPV of 96% (94-98%). Pooled data for ThyroSeq studies on 530 thyroid nodules showed a sensitivity of 95.1% (91.1-97.4%), specificity of 49.6% (29.3-70.1%), PPV of 70% (55-83%), and NPV of 92% (86-97%). There was no statistically significant difference in diagnostic performances of the two tests (p-values for sensitivity = 0.89, specificity = 0.82, PPV = 0.43, NPV = 0.17). CONCLUSION: High sensitivity and high NPV in GSC and Thyroseq v3 have potential to help rule out malignancy among thyroid nodules with indeterminate cytology results. There was no difference in diagnostic performances between the two molecular tests indicating that either test is appropriate to determine the malignancy of thyroid nodules. Further long-term outcome data are warranted to make a clear recommendation.

Perioperative Morbidity and Outcomes in Pediatric Patients Transitioned From Extracorporeal Membrane Oxygenation to Ventricular Assist Device Support: A Study of the Society of Thoracic Surgeons Congenital Heart Surgery Database.

As a bridge to transplant strategy, children transitioned from extracorporeal membrane oxygenation (ECMO) to ventricular assist device (VAD) have higher waitlist mortality compared with those who receive de novo VAD. However, the contribution of the immediate perioperative period and differences in the two groups are not well studied. We performed a nested case-control study between children receiving de novo VAD (group 1) and those transitioned from ECMO to VAD (group 2) between 2014 and 2019 using The Society of Thoracic Surgeons (STS) database. A total of 735 children underwent VAD placement with 498 in group 1 and 237 in group 2. Patients in group 2 were significantly younger, smaller, and significantly sicker, were twice as likely to transition to biventricular VAD and need unplanned reoperations. Overall mortality was 16% for group 1 and 34% for group 2 ( p < 0.01). Regression analysis showed that ECMO use (odds ratio [OR], 2.17 [1.3-3.4]), ventilator need (OR, 2.2 [1.3-3.9]), and cardiogenic shock (OR, 1.8 [1.2-2.8]) were all independent preoperative predictors of VAD mortality while dialysis need (OR, 25.5 [8.6-75.3]), stroke (OR, 6.2 [3.1-12.6]), and bleeding (OR, 1.9 [1.1-3.4]) were independent postoperative predictors of VAD mortality within 30 days (all p < 0.05). The study demonstrated significant baseline differences between the two cohorts, warranting avoidance of comparison. Early elective VAD placement in this cohort of patients should be sought to avoid interim ECMO and high post-VAD mortality.

Practice patterns of female cardiothoracic surgeons older than age 58 years: Are we making progress?

OBJECTIVE: Women remain a small minority of cardiothoracic surgeons, and within adult cardiac surgery, the gender gap widens. This study examines the career pathway and trajectory of female adult cardiac surgeons. METHODS: Female cardiothoracic surgeons were identified from the American Board of Thoracic Surgery diplomates over 58 years. Publicly available information was obtained to determine years in practice, practice type, academic and leadership title(s), and location of practice. RESULTS: The average number of years in practice for female adult cardiac surgeons was 13.1. Those categorized as adult cardiac surgeons composed 25.4% (n = 90) of all female cardiothoracic diplomates and 134 (37.9%) were categorized as other subspecialty practice. Of the adult cardiac surgeons, 33.3% (n = 30) practiced privately and the remainder in academic practice. Academic titles were held by 47.8% (43 out of 90) and 30% (27 out of 90) held a position of leadership. Of those in academic practice, 25% (11 out of 42) are titled professor, whereas 43% (18 out of 42) are assistant professors. Most commonly, those in positions of leadership held the title "director," which reflects 37% (10 out of 27) of individuals. Practice locations were distributed throughout the United States, with the highest number in the northeast (26.7%). CONCLUSIONS: Only a small portion of female cardiothoracic surgeons pursue a career in adult cardiac surgery compared to their male counterparts. From 1999 to 2009, 1300 individuals were board certified cardiothoracic surgeons, of whom only 103 (7.9%) were female. Of these, the majority of female cardiothoracic surgeons entered academic practice. Although the overall number of practicing female adult cardiac surgeons has increased with a growth rate of 10.7%, this number remains extremely low. A discrepancy remains between gender representation of academic titles and leadership positions. Although the field has increased female representation over the past few decades, work remains to ensure all potential talent is encouraged and supported.

The Thoracic Surgery Medical Student Association: Understanding the needs of medical students pursuing cardiothoracic surgery in the United States.

OBJECTIVE: Founded in 2020, the Thoracic Surgery Medical Student Association is the first national organization dedicated to supporting medical students interested in pursuing cardiothoracic surgery. Our inaugural survey aimed to describe their basic characteristics and needs. METHODS: An Institutional Review Board-approved, nonincentivized, anonymous electronic survey was distributed to any medical students enrolled in Liaison Committee on Medical Education-accredited medical schools through social media such as Twitter, national organizations (Association of Women Surgeons, Thoracic Surgery Resident Association), and medical school cardiothoracic surgery interest groups. Their basic characteristics, attitudes, and preferences regarding cardiothoracic surgery were recorded. RESULTS: Of the 167 students from 117 unique schools who completed the survey, 53% identified as White and 57% identified as female. Stages of training were well distributed: 16% first-year medical students, 33% second-year medical students, 16% third-year medical students, 21% fourth-year medical students, and 14% dual degree/research students. Most participants (57%) did not have (32%) or were not aware of having (25%) a thoracic surgery training program at their home institution. The majority (72%) of students reported not having a cardiothoracic surgery interest group at their home institution. The most desired areas of cardiothoracic were networking (31%) and mentorship (28%). CONCLUSIONS: There is a significant need to directly engage medical students who are interested in cardiothoracic surgery considering limited exposure at home institutions through a lack of cardiothoracic surgery interest groups and cardiothoracic residency programs. The Thoracic Surgery Medical Student Association is poised to address these areas with directed networking by connecting cardiothoracic surgery faculty and residents from other institutions with medical students interested in pursuing cardiothoracic surgery.

Impact of COVID-19 on Otolaryngology Literature.

OBJECTIVES/HYPOTHESIS: To understand the effect of the COVID-19 pandemic on the volume, quality, and impact of otolaryngology publications. STUDY DESIGN: Retrospective analysis. METHODS: Fifteen of the top peer-reviewed otolaryngology journals were queried on PubMed for COVID and non-COVID-related articles from April 1, 2020 to March 31, 2021 (pandemic period) and pre-COVID articles from the year prior. Information on total number of submissions and rate of acceptance were collected from seven top-ranked journals. RESULTS: Our PubMed query returned 759 COVID articles, 4,885 non-COVID articles, and 4,200 pre-COVID articles, corresponding to a 34% increase in otolaryngology publications during the pandemic period. Meta-analysis/reviews and miscellaneous publication types made up a larger portion of COVID publications than that of non-COVID and pre-COVID publications. Compared to pre-COVID articles, citations per article 120 days after publication and Altmetric Attention Score were higher in both COVID articles (citations/article: 2.75 ± 0.45, P < .001; Altmetric Attention Score: 2.05 ± 0.60, P = .001) and non-COVID articles (citations/article: 0.03 ± 0.01, P = .002; Altmetric Attention Score: 0.67 ± 0.28, P = .016). COVID manuscripts were associated with a 1.65 times higher acceptance rate compared to non-COVID articles (P < .001). CONCLUSIONS: COVID-19 was associated with an increase in volume, citations, and attention for both COVID and non-COVID articles compared to pre-COVID articles. However, COVID articles were associated with lower evidence levels than non-COVID and pre-COVID articles. LEVEL OF EVIDENCE: 3 Laryngoscope, 132:1364-1373, 2022.

Aseptic Revision Total Knee Can Be Performed as Part of a Short-Stay Arthroplasty Program: An Analysis of the National Surgical Quality Improvement Program Database.

Total knee arthroplasty (TKA) is becoming an increasingly common procedure to alleviate knee pain often associated with osteoarthritis. As the number of revision TKAs performed continues to increase, there remains a debate regarding the efficacy of discharging patients earlier than the conventional 3 to 4 days in the postoperative period. A variety of studies have begun to show that interchangably discharge in the primary TKA setting has an economical benefit while causing either a reduction or no difference in patient outcomes. This study aims to determine the effect of rapid discharge at 0- to 2-day postoperative stay compared to the conventional 3- to 4-day postoperative stay on postdischarge complications in patients undergoing revision TKA. A retrospective cohort study was conducted using data collected through the American College of Surgeons National Quality Improvement Program Database. All patients who underwent aseptic revision TKA between 2005 and 2016 were identified and stratified into groups based on length of stay: 0 to 2 days versus 3 to 4 days. Patients suffering from predischarge complications were excluded to minimize bias. Single-component versus both-component revisions were analyzed. The incidence of adverse events following discharge was evaluated with univariate and logistic multivariate analyses where appropriate. Patients who underwent single-component revisions and were discharged rapidly were less likely to develop minor complications (p = 0.001; odds ratio [OR]: 0.355; 95% confidence interval [CI]: 0.188-0.671) and septic complications (p = 0.016; OR: 0.011; 95% CI: 0-0.430) within the 30-day postoperative period. No differences were observed in discharge cohorts among patients undergoing both-component revisions. We found that rapid discharge following aseptic revision TKA is not associated with increased risks for postoperative complications. Rapid discharge may have benefits for healthy patients undergoing single-component revisions. Careful selection of revision TKA patients for rapid discharge may help to lower the increasing costs of the procedure and improve patient outcomes. Further study is required to refine the selection criteria to identify patients eligible for short stay or outpatient revision TKA.

LVAD decommissioning for myocardial recovery: Long-term ventricular remodeling and adverse events.

BACKGROUND: Left ventricular assist devices (LVADs) mechanically unload the heart and coupled with neurohormonal therapy can promote reverse cardiac remodeling and myocardial recovery. Minimally invasive LVAD decommissioning with the device left in place has been reported to be safe over short-term follow-up. Whether device retention reduces long-term safety, or sustainability of recovery is unknown. METHODS: This is a dual-center retrospective analysis of patients who had achieved responder status (left ventricular ejection fraction, LVEF ≥40% and left ventricular internal diastolic diameter, LVIDd ≤6.0 cm) and underwent elective LVAD decommissioning for myocardial recovery from May 2010 to January 2020. All patients had outflow graft closure and driveline resection with the LVAD left in place. Emergent LVAD decommissioning for an infection or device thrombosis was excluded. Patients were followed with serial echocardiography for up to 3-years. The primary clinical outcome was survival free of heart failure hospitalization, LVAD reimplantation, or transplant. RESULTS: During the study period 515 patients received an LVAD and 29 (5.6%) achieved myocardial recovery, 12 patients underwent total device explantation or urgent device decommissioning, 17 patients underwent elective LVAD decommissioning, and were included in the analysis. Median age of patients at LVAD implantation was 42 years (interquartile range, IQR: 25-54 years), all had a nonischemic cardiomyopathy, and 5 (29%) were female. At LVAD implantation, median LVEF was 10% (IQR: 5%-15%), and LVIDd 6.6 cm (IQR: 5.8-7.1 cm). There were 11 hydrodynamically levitated centrifugal-flow (65%), and 6 axial-flow LVADs (35%). The median duration of LVAD support before decommissioning was 28.7 months (range 13.5-36.2 months). As compared to the turndown study parameters, 1-month post-decommissioning, median LVEF decreased from 55% to 48% (p = 0.03), and LVIDd increased from 4.8 cm to 5.2 cm (p = 0.10). There was gradual remodeling until 6 months, after which there was no statistical difference on follow-up through 3-years (LVEF 42%, LVIDd 5.6 cm). Recurrent infections affected 41% of patients leading to 3 deaths and 1 complete device explant. Recurrent HF occurred in 1 patient who required a transplant. Probability of survival free of HF, LVAD, or transplant was 94% at 1-year, and 78% at 3-years. CONCLUSIONS: LVAD decommissioning for myocardial recovery was associated with excellent long-term survival free from recurrent heart failure and preservation of ventricular size and function up to 3-years. Reducing the risk of recurrent infections, remains an important therapeutic goal for this management strategy.

Increased severity of anaemia is associated with 30-day complications following total joint replacement.

AIMS: The aim of this study was to determine the impact of the severity of anaemia on postoperative complications following total hip arthroplasty (THA) and total knee arthroplasty (TKA). METHODS: A retrospective cohort study was conducted using the American College of Surgeons National Quality Improvement Program (ACS-NSQIP) database. All patients who underwent primary TKA or THA between January 2012 and December 2017 were identified and stratified based upon hematocrit level. In this analysis, we defined anaemia as packed cell volume (Hct) < 36% for women and < 39% for men, and further stratified anaemia as mild anaemia (Hct 33% to 36% for women, Hct 33% to 39% for men), and moderate to severe (Hct < 33% for both men and women). Univariate and multivariate analyses were used to evaluate the incidence of multiple adverse events within 30 days of arthroplasty. RESULTS: Following adjustment, patients in the THA cohort with moderate to severe anaemia had an increased odds of 6.194 (95% confidence interval (CI) 5.679 to 6.756; p < 0.001) for developing any postoperative complication. Following adjustment, patients in the TKA cohort with moderate to severe anaemia had an increased odds of 5.186 (95% CI 4.811 to 5.590; p < 0.001) for developing any postoperative complication. Among both cohorts, as severity increased, there was an increased risk of postoperative complications. CONCLUSION: Preoperative anaemia is a risk factor for complications following primary arthroplasty. There is a significant relationship between the severity of anaemia and the odds of postoperative complications. Patients who had moderate to severe anaemia were at increased risk of developing postoperative complications relative to patients with mild anaemia. When considering elective primary THA or TKA in a moderately or severely anaemic patient, surgeons should strongly consider correcting anaemia prior to surgery if possible. Cite this article: Bone Joint J 2020;102-B(4):485-494.